Information Technology

Information Technology

General Application Information

(Sole Proprietor, Corporation, Partnership, LLC, etc)
(Describe typical services performed, customers served, products provided, etc.)

Sales Breakdown by % of revenue

Consulting and miscellaneous IT Services

Web casting and conferencing

Network Service or Access

Computer Manufacturing and Assembly

Total for the breakdowns above (should add up to 100%)
Do you work or sell product overseas

Current Insurance Information

MM slash DD slash YYYY
Note: Complete below or fax us your loss runs at 301-417-0040

Location / Building Information

If over 30 years old, years of updating for


Coverage/Rating Basis Information


Should include Leasehold Improvements(may also be included in building so obtain a breakdown), Leased Property, Inventory, Furniture/Fixtures, Equipment, Printed Materials, Consumables, Property of Others

General Liability

Do you use sub-contractors?
Do you require sub-contractors to carry insurance and do you obtain certificates of insurance?

Worker's Compensation by State

Owner/Officer Information


Rented Vehicles used or Employee Vehicles Used in Business?

Owned Vehicle Schedule

NOTE: You may complete with Vehicles and Drivers below, or fax us your list at 301-417-0040

Drivers Schedule (if you own vehicles)

(List all employees who drive any vehicle on company business)
MM slash DD slash YYYY

Prior Claim/Loss Information

Have you had any prior claims or losses?

Other Optional Coverage to Consider

Do you need coverage for trips or work outside the United States?
Would you like an optional Umbrella Quote?
Would you like an Employee Benefits Quote (health, life, disability, long-term care)?
Would you like an Employment Practices Liability Quote?